1. health and fitness
2. disease
3. cancer

Know Your Options
A Prostate Cancer
Education Program
Understanding
Treatment
Choices for
Prostate Cancer
US TOO International, Inc.
National Cancer Institute
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
National Institutes of Health
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
What Is the Prostate Gland? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Is It Prostate Cancer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Grading the Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Staging the Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Lymph Nodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Second Opinions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Making Treatment Choices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Treatment Options for Localized Disease . . . . . . . . . . . . . . . . . . . 12
Watchful Waiting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
The procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Possible problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Radiation Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
External beam radiation therapy . . . . . . . . . . . . . . . . . . . . . 16
Possible problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Internal radiation therapy . . . . . . . . . . . . . . . . . . . . . . . . . 17
Possible problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Has Spread . . . . . . . . . . . . . 19
. . . . . . . . . . . . . . . . . . . . . . . 19
. . . . . . . . . . . . . . . . . . . . . . . 20
. . . . . . . . . . . . . . . . . . . . . . . 20
. . . . . . . . . . . . . . . . . . . . . . . 20
. . . . . . . . . . . . . . . . . . . . . . . 21
. . . . . . . . . . . . . . . . . . . . . . . 22
Conformal radiation therapy . . . . . . . . . . . . . . . . . . . . . . . 22
Complementary Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Treatment Options for Disease That
Hormonal Therapy . . . . . . . . . . .
Possible problems . . . . . .
Clinical Trials . . . . . . . . . . . . . . .
Cryosurgery . . . . . . . . . . . .
Early hormonal therapy . . . .
Chemotherapy . . . . . . . . . .
Considering Your Chances of Survival
Stage I and Stage II . . . . . . . . . . . . .
Stage III . . . . . . . . . . . . . . . . . . . . .
Stage IV . . . . . . . . . . . . . . . . . . . . .
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23
23
24
25
Pain Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
The Decision Is Yours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Questions To Ask Your Doctor . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Followup Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Glossary
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
“When my doctor said, ‘General, you have prostate
cancer,’ I was thrust into an immediate and fearful
state of confusion. I can still recall my inability to
move a muscle for what seemed like an eternity after
hearing my diagnosis.
As I look back, I am thankful for the many resources
available to me: my doctor’s skill and the unwavering
support of my family and loved ones. But another
resource I am most thankful for was the availability
of an abundance of information that helped me plan
my own fight against this dreaded disease.”
General H. Norman Schwarzkopf
U.S. Army (retired)
Commander in Chief, United States Central Command
Operation Desert Shield/Desert Storm
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Know Your Options A P r o s t a t e C a n c e r E d u c a t i o n P r o g r a m
Foreword
Introduction
his year in the United States,
almost 180,000 men will be
told that they have prostate cancer.
After a diagnosis of prostate
cancer, a man and his family face
several choices regarding treatment.
Decisions involve many factors,
personal as well as medical. Before
making these decisions, it is very
important that he learns about all
the options available.
This booklet can help a man
and his family understand what a
diagnosis of prostate cancer means
and what treatment choices are
offered. It suggests questions to ask
the doctor and identifies other
resources for more information.
To help you understand the meaning of the words you will hear used
to describe your cancer, medical
terms are printed in bold type and
are explained in the Glossary section at the back of this booklet.
With this knowledge, a newly
diagnosed prostate cancer patient
can participate more confidently
with his doctor in planning his
individual treatment.
P
rostate cancer is common in
older men. By age 50, about
one-third of American men have
microscopic signs of prostate cancer.
By age 75, half to three-quarters
of men will have some cancerous
changes in their prostate glands.
Most of these cancers remain latent,
producing no signs of symptoms, or
are so indolent, or slow-growing,
that they never become a serious
threat to health.
A much smaller number of
men will actually be treated for
prostate cancer. About 16 percent of
American men will be diagnosed
with prostate cancer during their
lives; 8 percent will develop significant symptoms; and 3 percent will
die of the disease.
Until the last several years,
prostate cancer death rates had been
rising steadily. For example, this
cancer in 1932 killed 17 of every
100,000 American men. By 1991,
this number had reached 25 in
100,000. Since then, however, the
death rates have been declining. The
reasons for both the earlier increase
and the recent decline in the prostate
cancer death rates are unclear.
T
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Rectum
Bladder
Prostate
Penis
Urethra
Testis
Digital Rectal Exam
Seminal
Vesicles
Prostate
Prostate
Cancer
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What Is the
Prostate Gland?
Is It Prostate
Cancer?
he prostate gland, a key part of
the male reproductive system, is
linked closely with the urinary
system. It is a small gland that
secretes much of the liquid portion
of semen, the milky fluid that transports sperm through the penis
during ejaculation.
The prostate is located just
beneath the bladder, where urine is
stored, and in front of the rectum.
It encircles, like a donut, a section
of the urethra. The urethra is the
tube that carries urine from the
bladder out through the penis.
During ejaculation, semen is secreted by the prostate through small
pores of the urethra’s walls.
The prostate is made up of
three lobes encased in an outer covering, or capsule. It is flanked on
either side by the seminal vesicles,
a pair of pouch-like glands that contribute secretions to the semen. Next
to the seminal vesicles run the two
vas deferens, tubes that carry sperm
from the testicles. The testicles, in
addition to manufacturing sperm,
produce testosterone, a male sex
hormone that controls the prostate’s
growth and function.
C
ompared with most cancers,
cancer of the prostate tends to
grow slowly. Decades may pass from
the time the earliest cell changes can
be detected under a microscope
until the cancer progresses enough
to cause symptoms.
Like other cancers, prostate
cancer can be diagnosed only by
examining tissue under the microscope. When your doctor suspects
prostate cancer—on the basis of
your symptoms, or the results of a
digital rectal exam (DRE), and/or
a prostate-specific antigen (PSA)
test—the diagnosis must be made
by doing a biopsy.
T
BIOPSY
To get a biopsy, you will go to a
urologist and the procedure will
be performed in the doctor’s office.
Using a transrectal ultrasound
(TRUS) probe, the doctor first
images your prostate, then inserts
hollow biopsy needles into areas of
the gland that feel or look suspicious.
Bits of tissue are removed from each
site through the needles; each snip
causes a sharp sting. If a tissue sample
is taken because of an elevated PSA
test rather than a suspected abnormal
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is likely to be slow-growing, while
one with a high grade is more likely
to grow aggressively or already to
have spread outside the prostate
(metastasized). The most widely
used grading method for prostate
cancer is known as the Gleason
grading system (see Gleason Scores,
page 7).
Tumor grade is useful as a
predictor of outcome. In one analysis,
10 years after prostatectomy for
localized cancer, prostate cancer
had claimed the lives of 6 percent
of the men whose cancers were welldifferentiated compared with 20
percent of those with moderately
differentiated cancers and 23 percent
of those with poorly differentiated
cancers. The chances of developing
metastatic prostate cancer followed
a similar pattern. Ten years after
surgery, metastases had been diagnosed in 13 percent of the men
with well-differentiated tumors, but
in 32 percent of those with cancers
that were moderately differentiated
and 48 percent of those whose cancers
were poorly differentiated.
area in the prostate gland, random
tissue samples are often taken from
six or more sectors of the prostate.
In a so-called pattern biopsy, tissue
samples are obtained from half a
dozen or more carefully spaced sectors of your prostate gland; this helps
establish the size and extent of any
cancer. However, even when multiple
samples are taken, biopsy can miss
some cancers.
Your biopsy tissue samples are
then examined by a pathologist, a
doctor who studies and identifies
the cell and tissue changes produced
by disease.
GRADING THE CANCER
Healthy prostate cells are uniform
in size and shape, neatly arranged in
the patterns of a normal gland. As
cancer grows, they lose their healthy
look. They change from normal,
well-differentiated tissues to more
disorganized, poorly differentiated
tissue. Eventually, a tumor develops.
If your biopsy shows the presence of prostate cancer, the pathologist assigns each tissue sample a
grade, indicating how far the cells
have traveled along the path from
normal to abnormal. The grade
offers a good clue to your tumor’s
behavior: a tumor with a low grade
S TA G I N G T H E C A N C E R
Once your cancer has been identified,
the doctor wants to know how large
it is and how far it has spread.
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Know Your Options A P r o s t a t e C a n c e r E d u c a t i o n P r o g r a m
Gleason Scores
The Gleason grading system assigns a grade to each of the
two largest areas of cancer in the tissue samples. Grades
range from 1 to 5, with 1 being the least aggressive and 5
the most aggressive. Grade 3 tumors, for example, seldom
have metastases, but metastases are common with grade 4
or grade 5.
The two grades are then added together to produce a Gleason
score. A score of 2 to 4 is considered low grade; 5 through 7,
intermediate grade; and 8 through 10, high grade. A tumor
with a low Gleason score typically grows slowly enough that it
may not pose a significant threat to the patient in his lifetime.
Regional
Stage III or C or T3: a tumor that
has grown through the prostate
capsule, perhaps into the seminal
vesicles.
Depending on its size and spread,
your doctor will stage your tumor.
Information on your tumor stage,
along with tumor grade and PSA
level, is central to choosing your treatment and to monitoring its success.
T4: a tumor that has grown into
nearby muscles and organs.
Tumor stages are:
Metastatic
Stage IV or D and N+ or M+:
tumors that have metastasized to
the regional (pelvic) lymph nodes
(N+) or more distant parts of the
body (M+).
Localized
Stage I or A or T1: a tumor that
cannot be felt (nonpalpable).
Stage II or B or T2: a tumor that can
be felt (palpable) but is confined to
the prostate gland.
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Staging Systems
One of two widely used staging systems, known as TNM,
evaluates Tumor size and spread, cancer in the nearby
lymph Nodes, and whether the cancer has established distant Metastases. The second system measures the same
tumor characteristics, but uses an ABCD rating.
PSA tests are playing an
increasingly common role in cancer
staging. Elevated PSA levels in the
blood correlate roughly with the
volume of cancer in the prostate,
with the stage and grade of the
tumor, and with the presence or
absence of cancer metastases or
growths in other tissues. (For more
about PSA, see Resources section,
page 30, to order a copy of
Understanding Prostate Changes:
A Health Guide for All Men.)
Valuable information about
tumor size and location can also be
obtained from TRUS used to guide
the biopsy in sampling abnormal
areas of the prostate. TRUS uses an
ultrasound probe inserted in the rectum to visualize the area on a screen.
The pathologist’s evaluation
of the biopsy samples also helps to
establish the clinical stage (size and
extent) of a cancer. The pathologist
Each of these stages is subdivided into more precise categories
(see Staging Systems, above).
In 1990, two-thirds of newly
diagnosed prostate cancers were
Stage I or II (clinically localized).
Slightly more than 10 percent were
Stage III (regional), while about 20
percent were Stage IV (metastatic).
The main tests used for
clinical staging of prostate cancer
are DRE, PSA, and transrectal ultrasound (TRUS). Bone scans may be
used when distant metastases are
suspected.
The digital rectal exam
(DRE), a procedure in which the
doctor inserts a gloved finger into
the rectum to examine the rectum
and prostate to look for an irregular or abnormally firm area, helps
to gauge tumor size, and it may
show if the cancer has spread into
nearby tissues.
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tors often recommend that these
patients can skip the bone scan.
Sophisticated imaging techniques such as computed tomography (CT) and magnetic resonance
imaging (MRI) can also help to
uncover distant metastases. Like
bone scans, however, such tests
may be unnecessary for some men.
Recent studies indicate that when
prostate cancer is clinically localized—the situation for two-thirds
of newly diagnosed cases—CT and
MRI add little to the information
available through DRE, PSA, and
TRUS.
tallies how many of the tissue samples contain cancer, notes whether
any of the samples are more than
half cancerous, and determines a
Gleason score.
When clinical staging suggests
that cancer has spread to the lymph
nodes or beyond, radionuclide
bone scans can be used to look for
metastases to bone, a common site
of prostate cancer spread. However,
research now shows that patients
with PSA levels of 10 ng/ml or less,
without bone pain, are so unlikely
to have bone metastases—regardless
of tumor stage or grade—that doc-
Toward Better Testing
The higher a man’s PSA level, the more likely that cancer could be in
the picture. During screenings in men ages 50 or older, 85 of every
100 men will have normal PSA levels (4 ng/ml or below). Among
the remaining 15 men, only 3 will have biopsies that show cancer.
Some recent refinements designed to make PSA testing more accurate
and more precise are under clinical study. For instance, PSA density
relates a man’s PSA level to the size of his prostate, which can be
estimated through ultrasound. PSA velocity is based on changes in
PSA levels over time; a sharp rise from a baseline level raises the
suspicion of cancer.
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LY M P H N O D E S
SECOND OPINIONS
When cancer occurs in the prostate,
the gland’s cells multiply abnormally
and may eventually grow through
the prostate capsule and invade
nearby tissue. It may also spread
to the lymph nodes of the pelvis,
or it may spread throughout the
body via the lymphatic system
or the bloodstream.
Carefully removing and
examining the lymph nodes—pelvic
lymph node dissection—has
traditionally been the final check
to see if cancer has spread. It may
be through “open” surgery or via
laparoscopy, using a fiberoptic
probe inserted through a small
incision in the abdomen. When
PSA level, tumor grade, and stage
are evaluated, doctors may choose
to bypass pelvic lymph node dissection. However, such clinical decisions
may be revised to take into account
new findings after surgery (prostatectomy). Pathologic staging judges
tissues removed at prostatectomy.
The pathologist looks for cancer in
outer areas of the gland and at the
surgical margins—the outermost
cut edges of the surgical specimen.
Once you receive your doctor’s
opinion about what treatments you
need, it may be helpful to get more
advice before you make up your
mind. Other doctors’ opinions can
help you make one of the most
important decisions of your life.
Getting another doctor’s advice is
normal medical practice, and your
doctor can help you with this effort.
Many health insurance companies
require and will pay for other opinions. Another opinion can help you:
• Confirm or adjust your treatment
plan based on the diagnosis and
stage of the disease.
• Get answers to your questions and
concerns and help you become comfortable with your decisions.
• Decide about taking part in clinical
trials of new prostate cancer treatment methods.
(See Clinical Trials, page 20.)
You may also consider contacting a prostate cancer support
group in your area. Talking with
other men who have experienced
the various procedures available
may help you to understand better
the treatment options described by
your doctor.
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Know Your Options
Questions to Consider
Making Treatment
Choices
Many questions will need answers.
f you have been diagnosed with
prostate cancer, you may be overwhelmed with an array of treatment
options. Your course of action will,
to some extent, be influenced by the
character of your cancer. Your decisions should also reflect your personal priorities after weighing each
potential benefit and possible harm
for the treatment options available.
Your age and health should also be
considered.
Treatment decisions are complicated by shortcomings in both
prognosis and treatment. Although
your Gleason score and PSA level
provide good guidelines, there is still
no way to know for sure how rapidly
your prostate cancer will progress.
Nor are there any results available
from clinical trials that directly
compared different types of treatment for similar stages of disease to
help you evaluate possible options.
I
• Is your cancer truly confined
to the prostate gland, or has it
spread to nearby—or even
distant—parts of your body?
• Is it aggressive or slow-growing?
• What is your general health
status?
• Are you young enough so that
even a slow-growing cancer
might someday pose a threat?
• Are you healthy enough for
surgery?
• Are you willing to risk
serious, lifelong side effects to
possibly reduce your chances
of a cancer death?
• How important is it for you,
in your work or recreation, to
maintain bladder or bowel
control?
• How important is it to be able
to have erections?
• Or would you find it too
worrisome to live with an
untreated cancer, too stressful
to face frequent monitoring?
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side, watchful waiting risks decreasing the chance to control disease
before it spreads, or postponing
treatment to an age when it may be
more difficult to tolerate. Of course,
treatments may also improve over
time if watchful waiting is chosen.
Another potential disadvantage is
anxiety; some men don’t want the
worry of living with an untreated
cancer.
The most obvious candidates
for watchful waiting are older men
whose tumors are small and slowgrowing, as judged by low grade/
Gleason score and low stage.
Many men who choose
watchful waiting live for years with
no signs of disease. A number of
studies have found that, for at least
10 or even 15 years, the life expectancy of men treated with watchful
waiting (primarily older men with
less lethal forms of prostate cancer)
is not substantially different from the
life expectancy of men treated with
surgery or radiation—or, for that
matter, of the population at large.
Treatment Options
for Localized
Disease
f your prostate cancer is confined
to the gland, or localized (Stage I
or II/low Gleason score), you are a
good candidate for treatments that
can result in long-term survival.
There are three main approaches to
managing localized cancer: watchful
waiting, surgery, and radiation
therapy.
I
WATCHFUL WAITING
Watchful waiting is based on the
premise that cases of localized prostate cancers may advance so slowly
that they are unlikely to cause men
—especially older men—any problems during their lifetimes. Some
men who opt for watchful waiting,
also known as “observation” or
“surveillance,” have no active
treatment unless symptoms appear.
They are often asked to schedule
regular medical checkups and to
report any new symptoms to the
doctor immediately.
Watchful waiting has the
obvious advantage of sparing a man
with clinically localized cancer—
who typically has no symptoms—
the pain and possible side effects of
surgery or radiation. On the minus
SURGERY
In the early 1990s, roughly 30
percent of prostate cancer patients
in the United States were treated by
surgery, 30 percent by radiation,
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“Conservative management (watchful waiting)
of localized prostatic cancer is difficult for the
physician to advise and the patient to accept, in
part because both public and physician education
(in the United States) have been focused on early
diagnosis and cure and because of the powerful
emotional impact provided by cancer mortality.”
—Willet Whitmore, M.D., Emeritus
Memorial Sloan-Kettering Cancer Center, New York
statistics, however, indicate that
since 1993, the rate of prostatectomies has been dropping.
and 20 percent by watchful waiting.
(Most of the rest were treated with
a combination of therapies.) In
Europe, by contrast, watchful
waiting constitutes the standard
treatment for asymptomatic
prostate cancer.
The popularity of surgery
in this country has grown tremendously in recent years. A study of
Medicare patients’ records found
that the number of men nationwide
receiving radical prostatectomy by
1990 was six times greater than the
number recorded for 1984, and the
increase was seen in all age groups,
from the youngest (that is, age 65)
to men in their eighties. Recent
The procedure
An operation called radical prostatectomy completely removes the
prostate and nearby tissues. A
radical prostatectomy is further
described in terms of the incisions
used by the surgeon to reach the
gland. In a retropubic prostatectomy, the prostate is reached
through an incision in the lower
abdomen; in a perineal prostatectomy, the approach is through the
perineum, the space between the
scrotum and the anus. In radical
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Prostatectomy also carries
the risk of serious long-term problems, notably urinary incontinence,
stool incontinence, and sexual
impotence. (The procedure also
makes it very unlikely for a man to
father children, since little ejaculate
is produced without the prostate.)
Most men experience urinary
incontinence following surgery.
Many continue to have intermittent
problems with dribbling caused by
coughing or exertion. A few men
permanently lose all urinary control.
Some men can be helped with an
artificial urinary sphincter, surgically
implanted, or with injections of collagen to narrow the bladder opening.
Infrequently men may develop
stool or fecal incontinence after
radical prostatectomy. Fecal incontinence is the loss of normal muscle
control of the bowels. Muscle damage can occur during rectal surgery.
Stool incontinence may also be
caused by a reduction in the elasticity
of the rectum, which shortens the
time between the sensation of the
stool and the urgent need to have
a bowel movement. Surgery or
radiation injury can scar and stiffen
the rectum.
At one time, prostatectomy
almost invariably resulted in sexual
impotence. Today, the risk of
prostatectomy, the surgeon excises
the entire prostate gland, along
with both seminal vesicles, both
ampullae (the enlarged lower sections of the vas deferens), and other
surrounding tissues. The section
of urethra that runs through the
prostate is cut away (and with it
some of the sphincter muscle that
controls the flow of urine).
Pelvic lymph node dissection
is done routinely as part of a
retropubic prostatectomy; with
a perineal prostatectomy, lymph
node dissection requires a separate
incision.
Possible problems
Radical prostatectomy is a complicated and demanding procedure
that typically requires general
anesthesia and takes 2 to 4 hours.
Patients stay in the hospital for
about 3 days, and need to wear a
tube to drain urine (catheter) for
10 days to 3 weeks. About 5 to 10
percent of patients experience surgery-related complications such as
bleeding, infection, or cardiopulmonary problems. There is a
small risk of death from surgery;
it is less for men who are young
and healthy than men who are
older and frail.
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function. (If a man has trouble
with erections prior to treatment,
nerve-sparing surgery is probably
not indicated.) Depending on age,
extent of disease, and type of surgery, the chances of impotence vary
widely—somewhere between 20
and 90 percent.
impotence may be reduced by
nerve-sparing surgery. This technique carefully avoids cutting or
stretching two bundles of nerves
and blood vessels that run closely
along the surface of the prostate
gland and are needed for an erection.
However, nerve-sparing surgery is not possible for everyone.
Sometimes the cancer is too large
or is located too close to the
nerves. Even with nerve-sparing
surgery, many men—especially
older men—become impotent.
Most men will lose a degree of sexual
RADIATION THERAPY
Radiation therapy uses high-energy
x-rays, either beamed from a machine
or emitted by radioactive seeds
implanted in the prostate, to kill
cancer cells. When prostate cancer is
A Survey of Prostate Cancer Patients
About 60 percent were unable to
have an erection firm enough for
intercourse—even though almost
all of them said that they had
been able to have erections to at
least some extent before surgery.
Half were between ages 65 and
70 years old at the time of
prostatectomy, half were age 70
or older.
Two-thirds reported problems
with urinary incontinence.
And one-fifth needed treatment
to relieve urinary complications
caused by scar tissue in the urethra. In the hands of the most
experienced surgeons—and for
younger men—some of these complications may be less common.
Nearly one-third used something
like absorbent pads to cope with
wetness.
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U n d e r s t a n d i n g Tr e a t m e n t C h o i c e s f o r P r o s t a t e C a n c e r
localized, radiation therapy serves as
an alternative to surgery. External
beam radiation therapy is also
commonly used to treat men with
regional disease, whose cancers have
spread too widely in the pelvis to
be removed surgically, but who have
no evidence of spread to the lymph
nodes. In men with advanced
disease, radiation therapy can help
to shrink tumors and relieve pain.
External beam radiation
therapy
External beam radiation therapy
generally involves treatments 5 days
a week for 6 or 7 weeks. The treatments cause no pain, and each session
lasts just a few minutes. In many
cases, if the tumor is large, hormonal
therapy may be started at the time
of radiation therapy and continued
for several years. (See page 19.)
The primary target is the
prostate gland itself. In addition, the
seminal vesicles may be irradiated
(since they are a relatively common
site of cancer spread). Radiating the
lymph nodes in the pelvis, once
common practice, has not proven to
produce any long-term benefits for
most patients, but it may be necessary in certain circumstances.
Possible problems
Because the radiation beam passes
through normal tissues—the rectum,
the bladder, the intestines—on its
way to the prostate, it kills some
healthy cells. Radiation to the rectum
often causes diarrhea, but the diarrhea—as well as radiation-induced
fatigue—usually clears up when
treatment is over.
Radiation can also cause a
variety of long-term problems. These
include proctitis, inflammation of
the rectum, with bleeding and bowel
problems such as diarrhea, and cystitis, inflammation of the bladder,
leading to problems with urination.
In addition, some 40 to 50 percent
of men treated with radiation therapy
become impotent.
With newer techniques,
available at state-of-the-art radiation
16
Know Your Options A P r o s t a t e C a n c e r E d u c a t i o n P r o g r a m
the skin of the perineum. Seeds
made of radioactive palladium or
iodine are delivered through the
needles into the prostate, according
to a customized pattern—using
sophisticated computer programs—
to conform to the shape and size of
each man’s prostate.
The implantation procedure
can be completed in an hour or two
under local anesthesia; the patient
typically goes home the same day.
The seeds emit radiation for
several weeks, then remain permanently and harmlessly in place.
Alternatively, some doctors use much
more powerful radioactive seeds
over a period of several days. Such
temporary implants, which require
hospitalization, may be combined
with low doses of external beam
radiation.
Because the experience with
modern internal radiation therapy
therapy centers, side effects may be
fewer. Higher-energy radiation beams
can be more precisely focused, while
computer technology allows a radiation oncologist to tailor treatment
to the anatomy of the individual
patient.
Internal radiation therapy
Radiation can also be delivered to
the prostate from dozens of tiny
radioactive seeds implanted directly
into the prostate gland. This
approach, known as interstitial
implantation or brachytherapy,
has the advantage of delivering a
high dose of radiation to tissues in
the immediate area, while minimizing damage to healthy tissues such
as the rectum and bladder.
As practiced today, internal
radiation therapy relies on ultrasound or CT to guide the placement of thin-walled needles through
The men most likely to do well after external
beam radiation therapy are the same as those most
likely to do well after radical prostatectomy or
watchful waiting: They have well-differentiated
Stage I or Stage II tumors.
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U n d e r s t a n d i n g Tr e a t m e n t C h o i c e s f o r P r o s t a t e C a n c e r
effects, takes less time to do, requires
less time in the hospital, and is less
costly than either external radiation
or surgery.
techniques is relatively recent and
limited to carefully selected patients,
long-term results are not yet known.
At 5 years, more than 90 percent of
patients remain free of disease.
Internal radiation therapy is
not well suited for large or advanced
tumors, or for men previously
treated with transurethral resection of the prostate (TURP) for
benign prostatic hyperplasia
(BPH), who run an increased risk
for urinary complications. For
men with small, well-differentiated
tumors, it may provide an option
that is less invasive, has fewer side
Possible problems
Post-implant discomfort can usually
be controlled by oral painkillers.
The man can expect a few weeks of
incontinence, but long-term complications such as prostatitis or urinary incontinence are uncommon
and generally not severe. Sexual
impotence occurs in about 15 percent of men under age 70 and 30 to
35 percent of men over age 70.
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Know Your Options A P r o s t a t e C a n c e r E d u c a t i o n P r o g r a m
alleviating the painful and distressing symptoms of advanced disease.
Further, it is being investigated as a
way to arrest cancer before it has a
chance to metastasize (See Clinical
Trials Web site http://cancertrials.
nci.nih.gov). Although hormonal
therapy cannot cure, it will usually
shrink or halt the advance of disease,
often for years.
Surgery to remove the testicles
(orchiectomy or surgical castration)
is usually an outpatient procedure.
The testicles are removed through a
small incision in the scrotum; the
scrotum itself is left intact. To help
offset the operation’s psychological
toll, some men opt for reconstructive surgery in which the surgeon
replaces the testicles with prostheses
shaped like testicles.
A variety of hormonal drugs
can produce a medical castration
by cutting off supplies of male hormones. Female hormones (estrogens) block the release and activity
of testosterone. Antiandrogens
block the activity of any androgens
circulating in the blood. Still another
type of hormone, taken as periodic
injections, prevents the brain from
signaling the testicles to produce
androgens.
Treatment Options
for Disease That
Has Spread
f your cancer has grown beyond
the prostate gland (Stage III), it
cannot be stopped with local therapies—although radiation therapy
can help to keep the tumor in check
and hormonal therapy may slow its advance. If your prostate cancer is metastatic (Stage IV), it is usually treated
with hormonal therapy, which can
relieve painful or distressing symptoms and slow the progress of disease.
Another option for metastatic disease
is to enter clinical trials and accept
new treatments that are being studied.
I
HORMONAL THERAPY
Hormonal therapy combats prostate
cancer by cutting off the supply of
male hormones (androgens) such as
testosterone that encourage prostate
cancer growth. Hormonal control
can be achieved by surgery to
remove the testicles (the main
source of testosterone) or by drugs.
Hormonal therapy targets
cancer that has spread beyond the
prostate gland and is thus beyond
the reach of local treatments such
as surgery or radiation therapy.
Hormonal therapy is also helpful in
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U n d e r s t a n d i n g Tr e a t m e n t C h o i c e s f o r P r o s t a t e C a n c e r
ically, temporarily interrupt the
progress of an advanced and advancing cancer.
Unfortunately, hormonal
therapy for metastatic disease works
only for a limited time. Remissions
typically last 2 to 3 years. Eventually,
cancer cells that don’t need testosterone begin to flourish, and cancer
growth resumes. When that happens, a variety of other, second-line
hormonal-type drugs (for example,
hydrocortisone or progesterone)
may be tried.
Possible problems
Either surgical castration (orchiectomy) or medical castration (hormonal
drug therapy) can produce a striking
response. Both approaches cause
tumors and lymph nodes to shrink
and PSA levels to fall. However,
both castration methods can cause
hot flashes, impotence, and a loss of
interest in sex. Medical castration by
treatment with hormonal drug therapy can cause breast enlargement
and can increase a man’s risk of
cardiovascular problems, including
heart attacks and strokes.
Hormonal therapy has been
tried in many combinations. One
approach, known as maximum
androgen blockade or complete
hormonal therapy, combines castration (either surgical or medical)
with an antiandrogen pill, taken
daily, for months or years. However,
studies show that single hormone
treatments have similar effectiveness
compared to maximum androgen
blockade. Combining surgery
with hormonal therapy appears to
relieve symptoms.
Medical castration by hormonal therapy can be costly, but,
unlike surgical castration, its effects
can be reversed by stopping the
drug. Moreover, halting hormone
treatments will sometimes, paradox-
CLINICAL TRIALS
Many techniques are being tried in
investigational studies. They have
not been used in enough patients or
for a long enough time to prove
themselves better than conventional
treatments.
Cryosurgery
Cryosurgery uses liquid nitrogen to
freeze and kill prostate cancer cells.
Guided by TRUS, the doctor places
needles in preselected locations in
the prostate gland. The needle tracks
are dilated for the thin metal cryo
probes to be inserted through the
skin of the perineum into the
prostate. Liquid nitrogen in the
cryo probes forms an ice ball that
freezes the prostate cancer cells; as
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Know Your Options A P r o s t a t e C a n c e r E d u c a t i o n P r o g r a m
PSA and Outcomes
The first use of PSA tests was to gauge the success of treatment. After the prostate—the source of PSA—has been eliminated by surgery, PSA levels can be expected to fall. If PSA
still can be detected, it suggests that some prostate cells still
may be present somewhere in the body. If, sometime in the
future, the PSA level begins to rise, it may be the first sign of
recurrence. Such a biochemical relapse typically precedes
clinical relapse—symptoms—by months or years. However,
it is not known if treatment should start again or change
based solely on a rise in PSA.
Now research suggests that pretreatment PSA levels may
provide another important clue to prognosis, independent of
stage and grade. In one study, nearly 90 percent of the men
with a low pretreatment PSA level (4 ng/ml or less) remained
free of any signs of relapse (either symptoms or a rising PSA
level) 5 years after surgery. But among men with a high
preoperative PSA level (20 ng/ml or higher), just one-quarter
remained relapse-free.
Early hormonal therapy
Early or neoadjuvant hormonal
therapy is started as soon as
prostate cancer is diagnosed, in
hopes of slowing the growth of
cancer that has spread into nearby
tissues or of cancer that has invaded
the lymph nodes. Given prior to
surgery, neoadjuvant hormonal
therapy often helps to shrink a
tumor.
the cells thaw, they rupture. The
procedure takes about 2 hours,
requires anesthesia (either general
or spinal), and requires 1 or 2 days
in the hospital.
During cryosurgery, a warming catheter inserted through the
penis protects the urethra, and
incontinence is seldom a problem.
However, the overlying nerve bundles usually freeze, so most men
become impotent.
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U n d e r s t a n d i n g Tr e a t m e n t C h o i c e s f o r P r o s t a t e C a n c e r
Chemotherapy
Chemotherapy, which kills fastgrowing cells, has not proven particularly effective against slow-growing
prostate cancer cells. Several promising new anticancer drugs are under
study, being added to either surgery
or radiation therapy for men with
Stage III prostate cancer. Chemotherapy is also being tried in conjunction with hormonal therapy for
men whose advanced cancers are no
longer responsive to hormonal therapy
alone.
C O M P L E M E N TA R Y
THERAPIES
In addition to medical treatment,
some cancer patients want to try
complementary therapies. Complementary therapies include acupuncture, herbs, biofeedback, visualization, meditation, yoga, nutritional
supplements, and vitamins. Some
prostate cancer patients feel that
they benefit from some of these
therapies.
Before you try any of these
therapies, you should discuss their
possible value and side effects with
your medical doctors. You should
let them know if you are using any
such therapies. Be aware that these
therapies may be expensive, and
some are not paid for by health
insurance. As with any treatment,
you should ask the therapist for
evidence of how the therapy has
helped others.
Conformal radiation therapy
A 3-dimensional conformal
radiation therapy (3D-CRT) uses
sophisticated computer software to
conform or shape the distribution
of radiation beams to the 3-dimensional shape of the diseased prostate,
sparing damage to normal tissue in
the vicinity of treatment.
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Know Your Options A P r o s t a t e C a n c e r E d u c a t i o n P r o g r a m
years. Few men with low-grade
localized disease die of prostate cancer.
The disease-specific survival rate—
which excludes deaths from other
causes—is close to 90 percent. In
other words, regardless of treatment—
watchful waiting, surgery, or radiation
therapy—such a man can consider
his cancer a chronic disease because
he is much more likely to die of
other causes than of prostate cancer.
Men with localized tumors
who opt for watchful waiting, if
they live long enough, may run a
greater risk of eventually developing
metastatic disease. In one series of
studies, the chance of developing
metastases within 10 years was 19
percent for men with well-differentiated tumors and 42 percent for
men with moderately differentiated
tumors.
Only one small study has
directly compared watchful waiting
with radical prostatectomy, and it
found no significant differences in
survival. More reliable answers
should be forthcoming from ongoing
trials. In a 15-year study known as
PIVOT (Prostate Cancer Intervention versus Observation Trial),
some 1,250 patients with clinically
localized prostate cancer (Stage I or
Stage II and low Gleason score) are
being randomly assigned to either
Considering
Your Chances
of Survival
our chances of being alive, and
disease-free, 10 or 15 years
after diagnosis are apt to depend
more on the stage and grade of your
cancer than on the choice of treatment. The best outlook, as might be
expected, is for patients with smaller,
slow-growing, well-differentiated
tumors. The good news is that
approximately three-quarters of all
newly diagnosed prostate cancers are
clinically localized (Stage I or Stage II).
About 15 percent are Stage III, and
11 percent are Stage IV.
Y
S TA G E I A N D S TA G E I I
If your prostate cancer is limited to
the prostate (Stages I or II) and it
is well or moderately differentiated
(Gleason score 7 or below), the 5year outcome is considered excellent
for all three treatment options:
watchful waiting, surgery, or radiation therapy. Even at the end of 10
years, few men with Stage I or II
and a low Gleason score will have
succumbed to prostate cancer.
With a median age of 72 at
diagnosis, many men with prostate
cancer die of a variety of other natural causes in the next 10 to 15
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U n d e r s t a n d i n g Tr e a t m e n t C h o i c e s f o r P r o s t a t e C a n c e r
capable of spreading, since up to
one-fourth of these patients will
experience the recurrence of prostate
cancer over the next few years. A
review of Medicare records from
around the country found that more
than one-third of the men initially
treated with radical prostatectomy
needed additional cancer treatment
in the next 5 years.
watchful waiting or radical prostatectomy. Similar trials comparing
watchful waiting to surgery or to
radiation therapy are under way in
Europe.
Surgery or radiation therapy
is chosen typically by those men
whose tumors, although apparently
localized, are more extensive or poorly
differentiated (Gleason score of 8
to 10). Without aggressive therapy,
around three-quarters of such men
will have developed metastatic disease
in the following 10 years, and twothirds will have died from prostate
cancer. Whether or not treatment
can change these outcomes is under
study.
The reality is that not all
seemingly localized cancers are, in
fact, limited to the prostate gland.
When examining excised biopsy
tissue, pathologists find that as
many as half show prostate cancer
that has broken through the capsule,
invaded the seminal vesicles, or
spread into the surgical margins or
lymph nodes. In other words, many
cancers that are clinically Stage I
or Stage II need to be reclassified
as Stage III after the pathologist
reports his findings. In other cases,
even some cancers that are clinically
staged and pathologically verified
as Stage I or II apparently are still
S TA G E I I I
If your prostate cancer is Stage III,
it is a regionalized tumor that has
spread beyond the prostate—through
the capsule that encloses the prostate
and perhaps into the seminal vesicles.
However, it has not yet, as far as can
be determined, reached the lymph
nodes or any more distant sites in
the body.
External beam radiation
therapy is often used to treat Stage
III cancers. Besides being less invasive
than surgery, it is better suited for
bulky tumors. A few men have
surgery, while others rely on watchful
waiting. Men whose tumors are
reclassified as Stage III after surgery
(because cancer is found to have
spread through the capsule or into
the lymph nodes) sometimes go on
to have radiation therapy postoperatively. Studies are in progress to
evaluate this approach.
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Know Your Options A P r o s t a t e C a n c e r E d u c a t i o n P r o g r a m
S TA G E I V
If your prostate cancer has spread to
the nearby lymph nodes or to distant
parts of the body, it is called metastatic prostate cancer. Hormonal therapy
will generally improve symptoms
and delay the progress of disease
for another 2 to 3 years. If just the
lymph nodes are involved, a man
may use hormonal therapy to delay
the progress of prostate cancer even
longer. However, the vast majority of
those with positive lymph nodes at
the time of getting hormonal therapy
will remain at risk of developing
additional metastatic disease within
10 years after the treatment. Bone
metastases tend to be less responsive
to hormonal therapy.
Stage III tumors are often
large enough to create difficulties
with urination. These may be treated in a variety of ways, including
radiation therapy, surgery, TURP,
and hormonal therapy.
The long-term prospects for
men with Stage III prostate cancer
depend on the extent of disease.
Once cancer has broken through the
prostate capsule, chances that the
disease will progress in the next 10
years are about 50-50. Spreading to
the seminal vesicles further increases
the likelihood of a recurrence. One
study, following up on men who
had been treated with radiation therapy 20 years earlier, found that close
to half of them eventually died of
prostate cancer, although nearly as
many had died of some other cause
with no sign of cancer recurrence.
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U n d e r s t a n d i n g Tr e a t m e n t C h o i c e s f o r P r o s t a t e C a n c e r
Pain Management
The Decision
Is Yours
ver time, metastatic prostate
cancer often stops responding
to hormonal therapy. Advancing
disease may be accompanied by
painful symptoms, usually involving the urinary tract or bones,
along with weakness, fatigue, and
weight loss.
Doctors, including specialists
in pain control, can offer a variety
of ways to counteract such symptoms and help the patient achieve
comfort. Radiation, with either
external beam radiation therapy or
periodic injections of bone-seeking
radioactive chemicals (radionuclides),
may ease pain caused by bone
metastases, and it may also delay
the progress of disease. Surgery can
be helpful in opening a blocked
urinary tract. Beneficial drugs include
steroids and other “second-line”
hormonal therapies, as well as painkillers. When pain cannot be entirely
eliminated, it can be effectively
relieved in the majority of patients.
O
n important consideration to
factor into your treatment
decisions is that success is not guaranteed. As many as half of the
apparently localized cancers turn
out, at surgery, to have already
spread. And up to one-fourth, despite
apparently successful surgery, will
produce a recurrence over the next
several years. Thus, while aggressive
treatment will be unnecessary for
some men, it will prove inadequate
for others.
In coming to a decision, you
may find it helpful to thoroughly
discuss your treatment options,
including benefits and side effects,
with your wife/partner. You may
also consider contacting your local
prostate cancer support group after
consulting with your primary care
physician and one or more specialists. Getting a second opinion and
different perspectives can be very
helpful.
Your decision does not need
to be rushed. Take time to explore
all your options. You may prefer a
teaching hospital or a cancer center
for treatment, choosing a surgeon or
radiation oncologist who has extensive experience in the newest, least
traumatizing techniques. You may
A
26
New Directions
Prostate cancer research is advancing on dozens of fronts.
Scientists are probing the basic causes of disease, developing markers to distinguish slow-growing cancers from
aggressive cancers, and testing drugs to control or reduce
risk for prostate cancer. Most of the results are preliminary at
present.
Genes and prostate cancer. Researchers are exploring numerous links between genes and the development of prostate
cancer. They have identified several genes that may affect
a prostate cancer’s ability to spread (metastasize), a gene
change spurred by hormonal therapy, and a gene flaw that
interferes with the body’s defenses against environmental
carcinogens. The presence of multiple identical genetic segments (DNA repeats), which appear to intensify signals that
order the cell to multiply, may provide a better way to predict
a cancer’s aggressiveness.
Control. Researchers are investigating the possibility that
drugs might keep latent prostate cancers from developing
into active cancers. In NCI’s Prostate Cancer Prevention
Trial (PCPT), 18,000 healthy men age 55 and older are taking
either finasteride (currently used to shrink the prostate in
benign prostatic hyperplasia) or a placebo every day for 7 to
10 years. Smaller trials are testing DFMO, a drug that inactivates an enzyme that cells need in order to multiply, and
4-HPR, a vitamin A analog that may block hormone-responsive tumors.
Reduce risk. Since prostate cancer is less common in populations with low-fat, high-fiber, high-soy diets, scientists are
also looking into the possibility of using diet to prevent
prostate cancer from developing. There is still no evidence to
show that switching to a healthy diet after years of eating
high-fat foods will make a difference, but small studies are
testing the effects of a low-fat, high-soy diet among men
who have an increased risk of prostate cancer and men who
have already been treated for prostate cancer. There is some
evidence of a lower incidence of prostate cancer in men who
eat lots of tomato-based foods, especially tomato sauce
cooked with a little olive oil.
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U n d e r s t a n d i n g Tr e a t m e n t C h o i c e s f o r P r o s t a t e C a n c e r
want to take part in a clinical trial
evaluating new approaches. You will
also want to keep abreast of new
developments, checking with sources
such as NCI’s Cancer Information
Service (1-800-4-CANCER). Ultimately, the decision rests with each
individual. Each man has his own
priorities and knows best which
choices feel most comfortable for him.
• Could my symptoms be a sign of
cancer?
Questions To Ask
Your Doctor
• What is my prognosis? Is recurrence
likely?
• What tests do you recommend? Why?
• If I don’t have cancer, what can I do
about my symptoms?
• If I do have cancer, what stage is it?
What grade? What is my PSA level?
• Would it be useful to get a second
opinion from a second pathologist?
e hope that this booklet
has answered many of your
questions about your prostate cancer
and treatment options. However, no
booklet can take the place of talking
directly with your health care professionals. If you don’t understand
the answers, ask them to explain
further.
Many men find it helpful to
write down their questions ahead of
time. Below are some of the most
common questions. You may have
others. Jot them down as you think
of them, and take the list with you
when you see your doctor.
W
• Do I need additional tests to look
for lymph node involvement or
metastases?
• What are my treatment options?
What are the benefits?
• What are the possible side effects?
How can they be managed?
• Are there clinical trials that would
be appropriate for me?
• What other doctors should I talk
with—a cancer specialist, a surgeon,
a radiation oncologist?
• How much experience does the doctor have? How many times a year
does he perform this procedure? If a
surgeon, is he familiar with nervesparing techniques?
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Know Your Options A P r o s t a t e C a n c e r E d u c a t i o n P r o g r a m
Followup Care
cancer survivor. For example, you
may be asked to have more PSA
tests, bone scans, or palliative treatment. If you find any unusual
changes in your body such as bone
pain or swollen lymph nodes, you
should call your doctor as soon as
possible.
epending upon your choice of
treatment for prostate cancer,
your doctor will make some recommendations for followup care. These
recommendations may include more
tests, and the results will be used to
make choices that should improve
your quality of life as a prostate
D
29
U n d e r s t a n d i n g Tr e a t m e n t C h o i c e s f o r P r o s t a t e C a n c e r
Resources
Get Relief From Cancer Pain
his booklet is a starting point
to help you understand your
prostate cancer diagnosis and treatment options. Your own doctors
and nurses are the best sources for
answers to your questions. As noted
throughout this booklet, NCI’s
Cancer Information Service (CIS)
can provide the latest cancer information and help you find prostate
cancer support groups in your
community.
The CIS is a nationwide
information and education network
for cancer patients and their families
and friends, the public, and health
professionals. One toll-free number,
1-800-4-CANCER (1-800-422-6237),
connects English- and Spanishspeaking callers all over the country
with the office that serves their area.
The number for callers with TTY
equipment is 1-800-332-8615.
You may request the following NCI booklets by calling
1-800-4-CANCER:
Managing Cancer Pain
T
Questions and Answers About Pain
Control
Taking Part in Clinical Trials: What
Cancer Patients Need To Know
What You Need To Know About
Prostate Cancer
Eating Hints for Cancer Patients
Taking Time: Support for People With
Cancer and the People Who Care
About Them
Facing Forward: A Guide for Cancer
Patients
When Cancer Recurs: Meeting the
Challenge Again
Advanced Cancer
S PA N I S H
El tratamiento de radioterapia: Guía
para el paciente durante el tratamiento
(Radiation Therapy: A Guide for
Patients During Treatment)
¿En qué consisten los estudios clínicos?
Un folleto para los pacientes de cáncer
(What Are Clinical Trials All About?
A Guide for Cancer Patients)
ENGLISH
Understanding Prostate Changes: A
Health Guide for All Men
Radiation Therapy and You: A Guide
to Self-Help During Treatment
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Know Your Options A P r o s t a t e C a n c e r E d u c a t i o n P r o g r a m
N AT I O N A L C A N C E R
INSTITUTE RESOURCES
C A N C E R I N F O R M AT I O N
S E RV I C E ( C I S )
FA X
CancerFax®
Includes NCI information about
cancer treatment, screening, prevention, genetics, and supportive
care. To obtain a contents list, dial
1-800-624-2511 or 301-402-5874
from your touch tone phone or fax
machine hand set and follow the
recorded instructions.
Provides accurate, up-to-date information on cancer to patients and
their families, health professionals,
and the general public. Information
specialists translate the latest scientific
information into understandable
language and respond in English,
Spanish, or on TTY equipment.
Toll-free: 1-800-4-CANCER
(1-800-422-6237)
TTY (for deaf and hard of hearing
callers): 1-800-332-8615
US TOO
I N T E R N AT I O N A L , I N C .
WEB SITE
Independent network of prostate
cancer support groups that help
newly diagnosed prostate cancer
patients. The US TOO Web site
is http://www.ustoo.com.
INTERNET
http://cancer.gov
NCI’s Web site contains comprehensive information about cancer
causes and prevention, screening
and diagnosis, treatment and survivorship; clinical trials; statistics;
funding, training, and employment
opportunities; and the Institute
and its programs.
31
U n d e r s t a n d i n g Tr e a t m e n t C h o i c e s f o r P r o s t a t e C a n c e r
Anus: The opening at the lower end
of the rectum through which solid
waste leaves the body.
Glossary
ABCD rating: A staging system for
prostate cancer. A and B refer to
localized disease, C to regional
disease, and D to cancer that has
spread throughout the body.
Asymptomatic: Producing no
symptoms.
Abdomen: The part of the body
that contains the stomach, intestines, and other organs. The prostate
is located in the lower part of the
abdomen, also known as the pelvis.
Baseline level (PSA): The average
of several PSA readings from blood
samples taken from an asymptomatic
man who is screened for prostate
cancer.
Aggressive, aggressively: Rapidly
growing when said of a tumor; an
active intervention when said of a
treatment such as surgery.
Benign: Not cancerous.
Benign prostatic hyperplasia
(BPH): Enlargement of the prostate.
BPH is not cancer, but it can cause
some of the same symptoms.
Ampullae: The enlarged lower
sections of the two vas deferens.
Androgens: Male hormones, including testosterone.
Biochemical relapse: The appearance
of increased numbers of biochemical
marker molecules such as PSA. May
indicate cancer recurrence.
Anesthetics: Drugs or gases that
produce a loss of feeling or awareness. A local anesthetic causes loss
of feeling in a part of the body. A
general anesthetic puts a person to
sleep.
Biopsy: The removal of a sample
of tissue, which is then examined
under a microscope to check for
cancerous changes.
Bladder: The organ where urine is
stored.
Antiandrogen: A drug that blocks
that activity of male hormones
circulating in the blood.
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Know Your Options A P r o s t a t e C a n c e r E d u c a t i o n P r o g r a m
Cardiovascular problems: Health
complications that involve the heart
and blood vessels throughout the
body.
Bone scan: A computer or film
image showing abnormal areas of
bone. A small amount of radioactive
material (radionuclide), injected
into the bloodstream, collects in the
bones, especially areas of abnormality.
The radioactivity it emits is detected
by a machine called a scanner.
Castration: Eliminating the supply
of the male hormone, testosterone,
either by surgery to remove the
testicles or by hormonal drugs.
Bowel: The long, tube-shaped organ
in the abdomen that completes the
process of digestion. There are both
small and large bowels. Also called
the intestine.
Catheter: A tube inserted into the
body. One type of catheter can be
inserted through the penis to allow
urine to drain out.
Catheterization: The insertion of
a tube through the penis into the
bladder to allow urine to escape.
Brachytherapy: See Internal radiation therapy.
Cancer: A term for diseases in which
abnormal cells divide without control. Cancer cells have the potential
to invade nearby tissues and to spread
through the bloodstream and lymphatic system to other parts of the
body.
Chemotherapy: Treatment with
anticancer drugs.
Clinical relapse: The appearance of
symptoms of cancer’s recurrence.
Clinical stage, staging: Exams and
tests to learn the extent of the cancer
within the body, especially whether
the disease has spread from the original site to other parts of the body.
Capsule: The tough outer covering
of the prostate gland.
Cardiopulmonary: Related to the
heart and lungs.
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U n d e r s t a n d i n g Tr e a t m e n t C h o i c e s f o r P r o s t a t e C a n c e r
Cryosurgery: A procedure that uses
liquid nitrogen to freeze and kill
abnormal cells.
Clinical trials: Research studies that
involve people. Each study is designed
to answer scientific questions and to
find better ways to prevent or treat
cancer.
Cystitis: Inflammation of the bladder,
often marked by painful urination.
Clinically localized cancer (prostate):
Cancer that is judged, on the basis of
physical examination and other clinical evidence, to be contained within
the prostate capsule.
DFMO: Difluoromethylornithine,
an inhibitor of an enzyme, ornithine
decarboxylase (ODC). ODC is
essential for the synthesis of
polyamines, a class of compounds
that play central roles in the growth
of cancerous tissues.
Computed tomography (CT)
scan: A series of detailed pictures of
areas inside the body; the pictures
are created by a computer linked
to an x-ray machine. Also called
computed axial tomography (CAT)
scan.
Diagnosis: Identifying a disease
first by its signs and symptoms and
then confirming by a pathologic
examination of biopsy tissue samples
or other tests.
Conformal radiation therapy
(3D-CRT): Radiation treatment
that uses sophisticated computer
software to conform or shape the
distribution of radiation beams to
the 3-dimensional shape of the
diseased prostate, sparing damage
to normal tissue in the vicinity of
treatment.
Differentiated (well-, moderately,
or poorly): A description of how
healthy and normal a cell or tissue
looks under the microscope. Welldifferentiated cells appear mature,
similar to one another, and orderly.
Poorly differentiated cells are irregular and misshapen. See Grade.
Digital rectal exam (DRE): A procedure in which the doctor inserts
a gloved finger into the rectum to
examine the rectum and prostate.
Cryo probe: An instrument filled
with liquid nitrogen used to kill
prostate cancer cells by freezing and
thawing them quickly, so the cancer
cells rupture.
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Know Your Options A P r o s t a t e C a n c e r E d u c a t i o n P r o g r a m
Disease-specific survival rate: A
measure of the proportion of people
who die from the specific disease
being studied, excluding deaths
from other causes.
Estrogen: A female hormone.
Estrogens are sometimes used in
the treatment of prostate cancer to
block the release and activity of
testosterone.
DNA: The protein that carries
genetic information. Every cell
contains a strand of DNA.
External beam radiation therapy:
Radiation treatment delivered from
a machine. See Radiation therapy.
DNA repeats: Multiple identical
stretches of genetic material.
Fecal incontinence: The loss of
normal control of the bowels. This
leads to stool leaking from the rectum (the last part of the large intestine) at unexpected times.
Early hormonal therapy: See
Neoadjuvant hormonal therapy.
Fiberoptic probe: A flexible, lighted
tube that a doctor can use to examine
areas inside the body.
Ejaculation: The release of semen
through the penis during sexual
climax. In dry (retrograde) ejaculation, semen spurts backward into
the bladder rather than out through
the penis.
General anesthetic: See Anesthetics.
Genes: The basic biological units
of heredity, found in all cells in
the body.
Environmental carcinogens:
Chemicals that can cause cancer in a
person who is exposed to a significant level of contamination.
Genetic: Pertaining to genes and
their heredity.
Enzyme: A natural substance that
affects the rate at which chemical
changes take place in the body.
Gland: An organ that produces and
releases one or more substances for
use by various parts of the body.
Erection: Swelling and hardening
of the penis in response to sexual
excitement.
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U n d e r s t a n d i n g Tr e a t m e n t C h o i c e s f o r P r o s t a t e C a n c e r
Hormone-responsive: Cancer that
responds to hormone treatment.
Gleason grade: A number from 1
to 5 indicating how different a sample of prostate tissue looks when
compared to normal prostate tissue.
Hormones: Body chemicals that are
secreted by glands, circulate in the
bloodstream, and produce specific
effects on target organs and tissues.
Gleason grading system: A method
widely used to characterize prostate
tumors. Low Gleason grades and
scores indicate slow-growing cancer.
High grades and scores indicate a
cancer likely to grow aggressively
and spread outside the capsule.
4-HPR: A vitamin A analog that may
block hormone-responsive tumors.
Image, imaging techniques:
Methods for obtaining pictures of
organs and tissues inside the body.
Common imaging techniques
include x-ray, ultrasound, CT scans,
MRI, and bone scans.
Gleason score: A number from 2 to
10, obtained by adding the Gleason
grades from the two most abnormal
areas in the prostate tissue being
examined.
Immune system: The complex set
of cells and organs that defends the
body against infection and disease.
Grade: A measure of how closely a
cancer resembles normal tissue, that
is, how well it is differentiated.
Tumor grade suggests the tumor’s
likely rate of growth. See Gleason
score, ABCD rating.
Impotence (sexual): Inability to
achieve an erection sufficient for
sexual intercourse.
Incidence (rate): The number of
cases diagnosed per 100,000 persons
in the population.
Hormonal-type drugs, therapy:
Treatment that prevents certain cancer cells from getting the hormones
they need to keep growing. For
prostate cancer, the supply of male
hormones can be blocked either
with hormonal drugs or by surgery
to remove the testicles.
Incision: A cut made in the body
during surgery.
Incontinence (urinary): Loss of
urinary control.
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Know Your Options A P r o s t a t e C a n c e r E d u c a t i o n P r o g r a m
Lymph: An almost colorless fluid
that travels through the lymphatic
system and carries cells and substances
that help fight infection and disease.
Indolent: Slow-growing.
Internal radiation therapy: The
use of tiny radioactive seeds—or
implants placed directly into or
next to the prostate gland—to kill
cancerous cells. This is also known
as interstitial implantation or
brachytherapy.
Lymph nodes: Small, bean-shaped
organs that are part of the body’s
immune defense system. Lymph
nodes are located throughout the
body along the channels of the
lymphatic system. Lymph nodes
are also called lymph glands.
Interstitial implantation: See
Internal radiation therapy.
Lymphatic system: The tissues and
organs (including bone marrow,
spleen, and lymph nodes) that produce and store cells and substances
that fight infection and disease. These
organs are connected by a body-wide
system of channels, similar to blood
vessels, that carry lymph, an almost
colorless fluid, and the infectionfighting cells it contains.
Invasive (procedure): “Invading”
the body’s barriers, typically by cutting or puncturing the skin or by
inserting instruments into the body.
Laparoscopy: A surgical procedure
in which a thin lighted tube is
inserted through a small incision in
the abdomen, allowing the doctor
to see inside the abdomen. Pelvic
lymph node dissection can be performed via laparoscopy.
Magnetic Resonance Imaging
(MRI): A procedure in which a
magnet linked to a computer is used
to create detailed pictures of areas
inside the body.
Latent: Present but inactive, producing no symptoms.
Localized prostate cancer: Cancer
that is confined to the prostate gland
(identified as Stage I or Stage II).
Malignant: Cancerous.
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U n d e r s t a n d i n g Tr e a t m e n t C h o i c e s f o r P r o s t a t e C a n c e r
Neoadjuvant hormonal therapy:
Drug therapy administered prior
to surgery or radiation, in hopes of
shrinking the tumor to make it easier
to remove or destroy. Also known
as early hormonal therapy.
Maximum androgen blockade:
Treatment to totally block the production of male hormones. Androgen
suppression is achieved by surgical
removal of the testicles, by taking
female sex hormones, or by taking
other hormonal-type drugs.
Nerve-sparing surgery: A surgical
technique that carefully avoids cutting or stretching two bundles of
nerves and blood vessels that run
closely along the surface of the
prostate gland and that are needed
for an erection.
Medical castration: The use of
drugs to cut off supplies of male
hormones.
Metastasis, metastases, metastasized: The spread of cancer cells
from one part of the body to another
by way of the bloodstream or the
lymphatic system. The cells in a
metastatic tumor are the same kind
of cells as those in the original
(primary) tumor.
Nonpalpable: Cannot be felt
(palpated).
Observation: See Watchful waiting.
Oncologist: A doctor who specializes in diagnosing and treating cancer.
Metastatic prostate cancer: Cancer
that has spread (Stage IV) to the
lymph nodes of the pelvis or to
more distant parts of the body.
Orchiectomy: Surgery to remove
the testicles.
Orgasm: Sexual climax.
Microscopic: Something so small
that it can be seen only when magnified by a microscope.
Palliative treatment: Therapy that
relieves symptoms such as pain or
blockage of urine flow, but is not
expected to cure the cancer. Its main
purpose is to improve the patient’s
quality of life.
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Know Your Options A P r o s t a t e C a n c e r E d u c a t i o n P r o g r a m
Pelvis: The lower part of the abdomen,
located between the hip bones.
Palpable: Can be felt (palpated).
Pathologic staging: Microscopic
evaluation of tissues removed at
biopsy or surgery.
Penis: The external male organ of
urination and reproduction.
Perineal prostatectomy: See
Radical prostatectomy.
Pathologically localized prostate
cancer: Cancer that is diagnosed by
microscopically examining a prostate
gland removed at surgery.
Perineum: The space between the
scrotum and the anus.
Pathologist: A doctor who specializes in identifying diseases through
the cell and tissue changes the diseases
produce.
PIVOT (Prostate Cancer Intervention versus Observation Trial): A
15-year study to see if men with
localized prostate cancer who are
assigned to watchful waiting do as
well as men treated with surgery.
Pattern biopsy: A biopsy taking
samples of tissue from half a dozen
or more carefully spaced sections of
the prostate gland.
Placebo: An inactive look-alike
drug (or other intervention).
Placebos may be used in clinical
trials evaluating the effectiveness of
a new drug or other treatment.
PCPT (Prostate Cancer Prevention
Trial): A study in which healthy men
are taking either the drug finasteride
or a placebo every day for 7 to 10
years to see if the drug helps to prevent prostate cancer.
Pretreatment PSA levels: PSA
readings from blood samples taken
from a man who is clinically and/or
pathologically diagnosed with
prostate cancer, but who has not
yet received treatment.
Pelvic lymph node dissection:
Removal of lymph nodes near the
prostate to determine if cancer has
spread.
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U n d e r s t a n d i n g Tr e a t m e n t C h o i c e s f o r P r o s t a t e C a n c e r
Proctitis: Inflammation of the rectum, often marked by pain, diarrhea,
and bleeding.
PSA density: A measure relating a
man’s PSA level with the size of his
prostate.
Prognosis: The probable outcome
or course of a disease; the chances of
complete recovery or recurrence.
PSA level: Concentration of prostatespecific antigen circulating in a man’s
blood.
Prostate enlargement: See Benign
prostatic hyperplasia.
Prostate gland: A male sex gland.
The prostate produces fluid that
forms part of the semen.
PSA test: A test that measures the
PSA level in a sample of blood. PSA
levels can be useful in detecting
prostate cancer, in staging prostate
cancer, and in monitoring response
to treatment.
Prostatectomy: Surgery to
remove the prostate. See Radical
prostatectomy.
PSA velocity: A measure indicating
how rapidly a PSA level rises over
time.
Prostatitis: Inflammation of the
prostate gland.
Radiation: Energy carried by waves
or by streams of particles. Various
forms of radiation, including x-rays,
can be used in low doses to diagnose
disease and in high doses to treat
disease.
Prosthesis, prostheses: An artificial
replacement part. It is possible to
replace the testicles with prostheses.
Radiation oncologist: A doctor
who specializes in using radiation
to treat cancer.
PSA (Prostate-specific antigen):
A protein produced by cells of the
prostate gland. PSA circulates in the
blood and can be measured with a
simple blood test. PSA levels go up
in the blood of some men who have
prostate enlargement or prostate
cancer.
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Know Your Options A P r o s t a t e C a n c e r E d u c a t i o n P r o g r a m
Radioactive seeds: Small, radioactive, chemically unstable particles
that are delivered precisely to cancer
cells to kill them using the energy
given off as the particles decompose.
Radiation therapy: The use of highenergy rays, such as x-rays, to kill
cancer cells. The rays can be either
beamed from a machine (external)
or emitted by radioactive seeds
implanted in the tumor (internal).
See Internal radiation therapy and
External beam radiation therapy.
Radionuclides: Radioactive chemicals.
Radionuclides are used in making
bone scans.
Radical prostatectomy: Surgery
to remove the entire prostate gland
along with nearby tissues such as the
seminal vesicles. Radical prostatectomy can be performed either through
an incision in the lower abdomen
(retropubic prostatectomy) or in the
space between the scrotum and the
anus (the perineum) (perineal
prostatectomy).
Rectum: The lower part of the large
intestine. The rectum stores solid
waste until it leaves the body
through the anus.
Recurrence, relapse: The reappearance of cancer after treatment has
been completed.
Regional (pelvic) lymph nodes:
For the prostate, lymph nodes in
the pelvic area.
Radioactive: Giving off radiation.
Radioactive iodine: An isotope
of iodine, which means that it is
chemically similar to iodine but
unstable, giving off energy over
several weeks as it decomposes.
Regional prostate cancer: Cancer
that has spread through the prostate
capsule, perhaps into the seminal
vesicles, but not yet into nearby
lymph nodes or beyond (identified
as Stage III).
Radioactive palladium: An isotope
that is unstable and gives off energy
over several weeks as it decomposes.
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U n d e r s t a n d i n g Tr e a t m e n t C h o i c e s f o r P r o s t a t e C a n c e r
Signs: Effects of disease that can
be observed and/or measured. An
elevated PSA level may be a sign
of prostate cancer. See Symptoms.
Remission: Disappearance of the
signs and symptoms of cancer.
When this happens, the disease is
said to be “in remission.” Remission
can be temporary or permanent.
Sperm: Male reproductive cells,
produced in the testicles.
Retropubic prostatectomy: See
Radical prostatectomy.
Sphincter: A band of muscle fibers
that can relax or tighten to open or
close a bodily opening or passage.
Scrotum: The pouch of skin that
contains the testicles.
Stage: The extent of a cancer.
Clinical and pathological evidence
are used to determine stage.
Seeds: See Radioactive seeds.
Semen: The thick, whitish fluid
released through the penis during
orgasm. Semen is made up of substances produced by the prostate,
the seminal vesicles, and other male
sex glands, and contains sperm that
come from the testicles.
Staging: Doing tests to establish the
extent of a cancer, especially whether
it has spread beyond its original
site to other parts of the body. See
TNM rating and ABCD rating.
Stool incontinence: See Fecal
incontinence.
Seminal vesicles: A pair of pouchlike glands, adjacent to the prostate,
that contribute substances to the
semen.
Support group: An association of
people whose shared experiences
allow them to offer one another
advice and encouragement.
Side effects: Unavoidable results
that may accompany treatment. The
potential side effects of prostate cancer treatment include incontinence
and impotence.
Surgery: An operation.
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Know Your Options A P r o s t a t e C a n c e r E d u c a t i o n P r o g r a m
TRUS (Transrectal Ultrasound):
The use of sound waves to image
the prostate. The sound waves are
emitted by an instrument inserted
into the rectum. As the waves
bounce off the prostate, they create
a pattern that is converted by a
computer into a picture. TRUS is
used to detect abnormal prostate
growth and to guide a biopsy of
the abnormal prostate area.
Surgical margins: The outermost
cut edges of tissue that has been
surgically removed.
Surveillance: See Watchful waiting.
Symptoms: Effects of disease as
experienced by the patient and/or
found by a health professional during
a physical examination. Pain, for
example, is a symptom. See Signs.
Tumor: An abnormal growth of tissue.
Tumors can be either benign (noncancerous) or malignant (cancerous).
Testicles: The pair of egg-shaped
glands, contained in the pouch-like
scrotum, that produce sperm and
male hormones. The testicles are
also called the testes.
TURP (Transurethral Resection of
the Prostate): Surgery for benign
prostatic hyperplasia. Performed
with instruments inserted through
the penis, TURP cuts away excess
prostate tissue.
Testosterone: A male sex hormone,
produced primarily by the testicles.
Testosterone plays an important role
in a man’s sexuality. It also fuels the
growth of prostate cancer.
Ultrasound: An imaging technique
that uses sound waves to produce
pictures (sonograms) of body tissues.
See TRUS.
TNM rating: A cancer staging
system that evaluates Tumor size
and extent of the primary tumor,
cancer in the nearby lymph Nodes,
and Metastases.
Ureters: The pair of tubes that carry
urine from the kidneys to the bladder.
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U n d e r s t a n d i n g Tr e a t m e n t C h o i c e s f o r P r o s t a t e C a n c e r
Vitamin A analog: A substance
similar in chemical structure to
Vitamin A.
Urethra (male): In males, a tube
extending from the bladder to the
tip of the penis. It carries urine
from the bladder and, during ejaculation, semen from the prostate
gland, out through the penis.
Watchful waiting: Forgoing aggressive therapies unless symptoms or
other signs of disease progress.
Watchful waiting with frequent
monitoring may be a treatment
option for both benign prostatic
hyperplasia and early-stage prostate
cancer. Also known as observation
or surveillance.
Urinary system: The bodily
system that controls urination,
which discharges fluids and waste
products from the bladder.
Urine: The fluid containing water
and waste products that is stored
in the bladder and discharged
through the urethra.
Well-differentiated: See
Differentiated.
X-ray: A high-energy form of radiation. X-rays form an image of body
structures by traveling through the
body and striking a sheet of film.
Urologist: A doctor who specializes
in disorders of the urinary system
and the male reproductive system.
Vas deferens: A pair of tubes that
carry sperm from the testicles to
the prostate gland.
44
he National Cancer Act, passed by Congress in
1971, made research a national priority. Since that
time, the National Cancer Institute (NCI), the lead
Federal agency for cancer research, has collaborated with
top researchers and facilities across the country to conduct innovative research leading to progress in cancer
prevention, detection, diagnosis, and treatment. These
efforts have resulted in a decrease in the overall cancer
death rate, and have helped improve and extend the lives
of millions of Americans.
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to the Government. The copyright for these materials
often remains in the hands of the originators, and it is
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NIH Publication No. 03-4659
August 2000
Reprinted 2003
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